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Different approaches to menopause treatment and hormone replacement therapy have caused controversy in recent months, while some GPs think there needs to be better communication and research about treating menopause.
InSight+ spoke with GPs and one lead researcher, and author of the standard menopause toolkit about approaches to oestrogen.
Dr Michael Mrozinski is a GP with Jandowae Multipurpose Health Service in Darling Downs, Queensland. Dr Mrozinski graduated in medicine from the University of Glasgow and is an RACGP Fellow. He relocated from Scotland to rural Australia to go into general practice, where he says he can make a bigger difference.
“A couple of years ago I started a social media channel, trying to make complicated medical things a bit easier for people to digest. I try to fill in gaps in my own knowledge,” he said.
Dr Mrozinski made a TikTok about menopausal health after becoming exasperated about the range of opinions regarding things like hormone replacement therapy.
“A lot of the messages I get on social media are from frustrated women about predominantly either menopausal symptoms, or other kinds of women’s health issues,” said Dr Mrozinski. “I’ve seen before as well is that women will say, I went to see my doctor for my HRT symptoms and they just put me on an antidepressant,” he said.
“I work in a rural hospital where there are no female doctors. Women tend to gravitate towards female GPs, which is only natural. So, I thought, I need to do a menopause course,” said Dr Mrozinski.
Controversial doses
“Dr Louise Newson had a teaching platform for health care professionals, which is successful in the UK. I started it and, one or two days later, there was a news article. Other doctors like Dr Jen Gunter said that Dr Newson was prescribing huge doses of oestrogen,” said Dr Mrozinski.
England’s independent regulator of health and social care, the Care Quality Commission (CQC), had begun investigating “information of concern” at clinics run by Dr Louise Newson. Dr Newson lost her British Menopause Society accreditation for prescribing high doses of hormone replacement therapy (HRT), the BBC reported in September this year.
“I think most doctors would say, right, there is a place for HRT, but I’m not giving people super physiological doses. The dose is well above what the normal would be,” said Dr Mrozinski.
Dr Mrozinski said that he had learned a lot from Dr Newson’s other work.
“I think it is a very nuanced discussion,” said Dr Mrozinski.
“There were two factions, and it was confusing,” he said.
“When I did my training back in 2015, when we did sessions on menopause, it would always be, ‘You’ve got your non-hormonal and your hormonal treatments, but hormonal treatments increase the risk of cancer, cardiovascular risk.’ So, it always had that caveat,” said Dr Mrozinski.
“Whereas actually the studies showed the increase in risk, if any, is minimal, and it should be an individual discussion between the doctor and the patient in front of them,” he said.
Dr Mrozinski said that he would be following up with a range of sources, including the Australian Menopausal Society, to become more educated.
“We need to change the way we communicate and get people engaged, because the stuff we’re doing just now is not working.”
Dr Ceri Cashell is a Sydney GP with a special interest in women’s health. Dr Cashell speaks on a wide range of platforms about menopause and hormone therapy and made a submission to the recent Senate Enquiry into Menopause.
“My interest in the hormonal aspect of women’s health was piqued about three years ago, when a patient with undiagnosed attention deficit disorder (ADD) said she’d started on testosterone, and it had been a gamechanger for her cognitive health,” said Dr Cashell.
“That sent me on a deep dive and really looking at how much oestrogen, progesterone and testosterone are involved in every single system in the body”.
“Menopause transition causes a doubling in the risk of cardiovascular disease. We suddenly see women losing their bone mass. And it probably explains why women have twice the incidence of dementia.”
“We were never taught this in our medical education. We’ve not considered people who are born with ovaries as different to people who are born with testes,” she said.
Dr Cashell said that she approves of Dr Newson’s work.
“Dr Newson tries to tailor her hormone therapy according to the individual,” she said.
“Dr Newson administers higher amounts of oestrogen, not a higher dose. It’s trying to achieve the same dose. She only does it to patients that need it, and it’s something that all of us who practice tailored menopause medicine do,” said Dr Cashell.
“Transdermal medications such as oestrogen gel and patches have at least a 10-fold variation between individuals,” she said.
“In a white paper produced by the International Menopause Society, I think it came out in October, they accepted that the oestrogen absorption through the skin varies hugely between individuals, and does need to be adapted,” she said.
A need for data
Dr Cashell said that there have not been enough studies done on HRT, even on licensed higher doses, eg 100 µg patch.
“There’s lots of us who are happy to contribute to that data. The problem is most of medical research is sponsored by the pharmaceutical industry. If you have a drug that’s already approved, you have no interest in getting data for higher doses. There’s no incentive,” she said.
Dr Cashell said that the information available for GPs isn’t clear.
“When guidance isn’t clear, it’s hard for regular GPs to know what to do. I want to see doctors feeling confident, understand their basic science, and giving women treatment that is appropriate for their symptoms, but that also reduces the risk of most serious chronic diseases,” she said.
Dr Cashell says that the future should include a national awareness campaign, better medical education for doctors, and affordable and accessible medication and treatment for patients.
The precautionary approach
Professor Susan Davis is Director of the Women’s Health Research Program at Monash University, a researcher and lead author of the Practitioner Toolkit for Managing Menopause.
“We are actually rich in availability of credible resources on menopause. The Australasian Menopause Society patient fact sheets have been taken up internationally, because they’re so good,” she said.
“I think it’s more about knowing where to get the resources. Jean Hales has fabulous webinars for women,” said Professor Davis.
“For the GPs, we’ve got the practitioner toolkit that is free and gives really simple guidance,” she said.
The importance of research
Professor Davis said that there needs to be more research done into increasing doses of oestrogen.
“I think there is a desperate need for research into the current formulations that we’re prescribing. And a lot of [it] is being prescribed with very little research-based knowledge,” said Professor Davis.
“There is a danger of people over-interpreting the available evidence and extrapolating from it for their own beliefs. And it’s important that medicine is practiced on evidence, not beliefs and anecdotes. And there are boundaries that you don’t cross in terms of patient safety,” she said.
“We have absolutely no data on the safety of prescribing high dose oestrogen. The highest dose patch available is 100 µg,” she said.
“One doctor has publicly stated that they have patients frequently on three 100 µg patches, and then high doses of progesterone to protect the lining of the uterus. They appear to believe that’s fine. The problem is, I have no idea what that does to breast cancer risk. I have no idea what that does to anything in the body,” said Professor Davis.
“If you want to use high doses, you do a clinical trial. I ended up sorting out a patient who was on six times the standard dose of oestrogen, recommended by a doctor,” said Professor Davis.
“I think patients should be truly informed with the evidence and know the risks of the therapy they’re taking. It’s very paternalistic,” said Professor Davis.
“Having said that, one of the biggest issues is we can’t get women to go into clinical trials.” she said.
“They’re just busy. And you’ve got to put yourself out to do this,” said Professor Davis.
Hangover fears
Professor Davis said that her research shows that health care professionals are not confident prescribing oestrogen.
“GPs and gynos believe that hormone therapy is the best thing to treat menopause, but they don’t feel confident in all the nuances of the prescribing. They don’t feel sufficiently skilful,” said Professor Davis.
“Our qualitative study showed women know hormone therapy is available, but see it as something you only take if your symptoms are terrible. Is that because women have been trained to, ‘Suck it up Princess?’ Or is it [the idea that] you should only take something if you’re really badly off, combined with hangover fears that maybe it’s not safe and natural?” she said.
Commercialised medicine
Professor Davis was strongly in support of author Kaz Cooke’s comments in the Senate Enquiry into Menopause.
“Women can be subject to so much predatory behaviour by people selling unproven therapies and marketing them as though they’re effective,” said Professor Davis.
“[Cooke] named a particular website selling nutritional supplements, many of which have been shown to be useless. And, as she said, why is the community not protected against this sort of predatory commercial behaviour? It’s an issue about regulation; the commercialisation of menopause,” said Professor Davis.
Professor Davis said that for almost two decades, menopause has been considered untreatable because the treatments were painted as dangerous.
“You’re not going to upskill the entire medical workforce in five minutes. It will take time,” she said.
“In 2014, we tried to get funding for a national study of menopause. And we were asked, ‘Why? You can’t treat with HRT, that gives them cancer.’ We ended up getting a study funded by the Bupa Health Foundation,” said Professor Davis.
“Now, 10 years later, everybody’s talking about menopause.”
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Enough already! We have known for twenty years that the benefits of HRT outweigh the risks.
Professor Rob Langer’s presentation at the recent International Menopause Society’s Congress in Melbourne (‘MHT and Breast Cancer: A Close Look at the Evidence and Strategy for Safe Practice’) leaves no question about this and highlights (yet again!) the appalling misrepresentation of the data from the WHI.
Those of us who have come up against the anti-HRT ‘regime’ over the years have seen how this issue has become politicized at the expense of the health and wellbeing of millions of women world-wide.
For far too long, too many health professionals have been mired in a kind of pernicious wokism that seeks to persecute anyone who dares to suggest that we follow the evidence and put the welfare of women first.
Dr Louise Newson has successfully shone a spotlight on this issue when others who should have spoken out more vehemently, have failed to do so. She is being targeted because of her success and her courage.
Women who are now in their sixties and seventies and have missed the window of opportunity to fully benefit from hormone therapy (and avoid long-term health consequences) may well seek recompense from a medical system that has put politics before science. Maybe this will prompt doctors to become better informed and have the courage to properly support women at this time of their lives.